Affordability of fluoride toothpaste and national prevalence of untreated dental caries in low- and middle-income countries: an ecological cross-sectional study

Affordability of fluoride toothpaste and national prevalence of untreated dental caries in low- and middle-income countries: an ecological cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Affordability of fluoride toothpaste and national prevalence of untreated dental caries in low- and middle-income countries: an ecological cross-sectional study Kiriko Sasayama, Eiko Saito, Daisuke Yoneoka, Erika Ota, Yasuko Momoi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7707685/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Dental caries disproportionately affects low- and middle-income countries (LMICs), where access to fluoride toothpaste is often limited by poor affordability. This study aimed to assess the affordability of ≥ 950 parts per million of fluoride (ppm F) toothpaste for the general population in LMICs and its association with the prevalence of untreated dental caries. Methods A cross‑sectional ecological survey was conducted between January and March 2023. Key-informants—medical professionals with extensive experience in LMICs—reported brand, fluoride concentration, pack size, and price for commonly used toothpastes. Prices were converted to United States dollars using average 2023 exchange-rates, product volumes were standardised to grams, and annual consumption assumed 3 g/day (twice daily brushing). Affordability was defined as the proportion of 2023 median annual income required to purchase a 1‑year supply per person. National prevalence of untreated caries (ages ≥ 5 years), per capita refined sugar availability (2019), gross domestic product (GDP) per capita (PPP), and Gini index were assembled from international databases. Multiple linear regression assessed associations between caries prevalence and affordability, adjusting for GDP, Gini, and sugar; log‑transformations were applied except for Gini. Results Data were obtained for 45 LMICs across Asia, Africa, Oceania, Latin America, and the Middle East. The mean annual cost of fluoride toothpaste was USD 30.87 (SD 18.74; range 4.91–87.26). The mean affordability ratio was 0.48% (SD 0.49%; range 0.09–2.33%). In regression analyses, only affordability showed a significant positive association with untreated caries prevalence (coefficient 0.08; 95% CI 0.01–0.16; p = 0.03); GDP per capita, Gini index, and sugar availability were not significant. Conclusions Affordability of ≥ 950 ppm F toothpaste varies substantially across LMICs and is significantly associated with the national prevalence of untreated dental caries. affordability fluoride toothpaste low- and middle-income countries dental caries Figures Figure 1 Background Oral diseases are among the most widespread non-communicable health challenges globally; they significantly affect the quality of life and impose considerable burdens on healthcare systems. Although a global downward trend in dental caries prevalence has been reported, particularly in high-income countries (HICs), substantial disparities persist between HICs and low- and middle-income countries (LMICs). Over the past three decades, HICs have reported an approximately 40% reduction in caries prevalence, with age-standardised rates declining by 3.6% and 3.0% between 1990 and 2019 in the permanent and primary dentitions, respectively [ 1 ]. In contrast, LMICs continue to face significant challenges owing to systemic inequities in access to care, quality of services, treatment costs, oral health education, and overall health literacy [ 2 – 4 ]. The determinants of oral diseases in LMICs are multifactorial, involving individual, sociocultural, environmental, and economic factors. Addressing oral health disparities requires comprehensive, context-specific preventive strategies. These include the widespread use of fluoride, improved oral health education, school- and community-based preventive initiatives, integration of oral healthcare into primary health systems, and development of supportive public health policies [ 5 – 7 ]. Among these, the use of fluoride and oral health education are particularly cost-effective and scalable interventions [ 5 , 6 ]. Brushing with a fluoride toothpaste combines mechanical plaque removal with the chemical prevention of dental caries [ 8 ]. The World Health Organization (WHO) recommends fluoride concentrations of 1000–1500 parts per million of fluoride (ppm F) for all age groups, and recognising its essential role in dental-caries prevention, added fluoride toothpaste to its Model List of Essential Medicines in 2021 [ 9 ]. Despite international guidelines, affordability of fluoride toothpaste remains inconsistent across income levels. In many low-income settings, out-of-pocket expenditures for oral healthcare pose a significant burden on household finances, making fluoride toothpaste inaccessible for a substantial portion of the population [ 10 , 11 ]. This limited accessibility may contribute to the persistently high prevalence of dental caries in these regions. Therefore, this study aimed to assess the affordability of ≥ 950 ppm F toothpaste, which are the most common commercially available concentrations, for individuals residing in LMICs. Specifically, we calculated the proportion of household income required to purchase fluoride toothpaste and examined the association between affordability and the national dental caries prevalence. Methods Study design A cross-sectional survey was conducted between January and March 2023 in LMICs to examine the affordability of toothpaste containing fluoride at concentrations effective for preventing dental caries. Data collection was facilitated by international organisations in Japan, enabling responses from 60 countries. Participants Survey participants were selected from medical professionals who had extensive work experience in developing countries and were affiliated with Japanese government agencies. These individuals were chosen because of their familiarity with local pharmaceutical products and living conditions, which allowed them to understand the research objectives and carry out the survey effectively, even in resource-constrained settings. Recruitment was conducted through existing networks of international organisations. A representative from a Japanese government organisation contacted medical professionals working abroad via email and invited them to participate in the survey. Those who expressed interest were provided with a detailed explanation of the study’s purpose, procedures, and confidentiality measures. Written informed consent was obtained from all participants following a full explanation of the study purpose, methods and secondary use of the data. The questionnaire was then sent directly by the principal investigator. As a token of appreciation, participants received shopping points equivalent to 4,000 JPY. Data collection Participants were instructed to consult local colleagues affiliated with international organisations and to select at least two—and preferably three—commonly available toothpaste products for purchase in their country. For each product, the survey captured the fluoride status (present/absent as stated on the primary packaging), product name, manufacturer or distributor, fluoride concentration (grams or ppm F), and net content (millilitres or grams). When fluoride status or concentration was uncertain, participants were asked to photograph the packaging and transcribe the stated fluoride information. To ensure consistency across regions, data were collected using a self-administered questionnaire. An English version of the questionnaire, developed specifically for this study, is provided as Supplementary File 1. All toothpaste products were standardised in terms of volume, while fluoride concentration and price per product were calculated based on the standardised volume. Products without information regarding the fluoride concentration were excluded. However, products containing 950 ppm F were included because their clinical efficacy is chemically comparable to that of products containing 1,000 ppm F [ 8 ]. Participants were requested to submit photographs of the primary containers and outer packaging, if available, for reference. Standardisation of toothpaste volume Owing to differences in the net volume in millilitres or net mass in grams across products and because the fluoride concentration was expressed in micrograms per gram or percentage of mass, standardisation was necessary. The toothpaste volume in millilitres was converted to grams at an assumed density of 1.3 grams/ millilitres [ 12 ]. The fluoride concentration as a percentage of mass was converted to ppm F using the molecular weight of sodium fluoride, acidulated phosphate fluoride, or sodium monofluorophosphate. Price conversion Only fluoride-containing toothpastes (≥ 950 ppm F) were included in the analysis. Prices were converted to United States dollars (USD) using the average exchange rates for the first half of 2023, as reported by the World Bank [ 13 ]. Toothpaste usage and its cost Based on previous studies, the amount of fluoride toothpaste consumed by an adult per instance was assumed to be 1.5 g [ 12 , 14 , 15 ]. The annual toothpaste consumption was calculated based on a twice daily brushing frequency. Affordability of fluoride toothpaste The affordability of fluoride toothpaste in each LMIC was defined as the ratio of the yearly cost of the toothpaste to the annual income of individuals according to the 2023 median income data obtained from Our World in Data [ 16 ]. Selection of variables The associations between caries prevalence and fluoride toothpaste prices in 2023, median annual income in 2023, economic indicators (gross domestic product [GDP] and Gini index) [ 17 ], and annual sugar consumption were analysed. Sugar consumption was selected as a key factor associated with caries risk based on the WHO dietary recommendations [ 18 ]. The latest Gini index values were obtained from the World Bank database [ 19 ]. The Gini coefficients range from 0 to 1, and values > 0.5 indicate substantial income inequality. Use of secondary data Sugar consumption data were initially sourced from WHO. However, owing to the suspension of data collection in 2022 during the coronavirus disease (COVID-19) pandemic, data from 2019 were used instead [ 20 ]. Similarly, the national prevalence of untreated dental caries was obtained from the 2019 comprehensive WHO dataset, which reports estimates for individuals aged ≥ 5 years [ 21 ]. Statistical Analysis Multiple linear regression analysis was performed, with dental caries prevalence as the dependent variable. The independent variables included the proportion of annual income required to purchase fluoride toothpaste, GDP, Gini index, and per capita sugar consumption. All variables, except the Gini index, were log-transformed to meet the assumption of normality. Multicollinearity among independent variables was evaluated using variance inflation factors. Statistical analyses were performed using SPSS Statistics (version 29.0; IBM Corp., Armonk, NY). Ethics approval and consent to participate This study was approved by the International University of Health and Welfare Ethics Committee (Approval No. 22-Im-043). All procedures were conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Written informed consent to participate was obtained from all respondents prior to data collection. Results Country participation and products Of 54 countries with participants who provided initial consent, survey responses were obtained from 45 countries. An average of 5 toothpastes per country was reported (241 entries in total), of which 170 had verified fluoride concentrations. Descriptive statistics Table 1 presents fluoride toothpaste prices and economic indicators for 45 countries across five regions. Across the 45 LMICs, the mean annual cost of fluoride toothpaste was USD 30.87 (standard deviation [SD] 18.74; range, 4.91–87.26). The mean fluoride concentration of the toothpastes was 1,329.6 ppm F (SD 147.19; range, 924–1,476.67). The affordability ratio averaged 0.48% (SD 0.49%; range, 0.09–2.33). Mean per capita refined sugar availability was 64.06 grams/day (SD 35.55; range, 8.5–134.8), mean prevalence of untreated caries 31.18% (SD 4.47%; range 22.8–40.7), mean GDP per capita USD 11,893.96 (SD 8,697.08), and mean Gini index 39 (SD 7.66). Association with caries prevalence Table 2 summarises the regression results. Affordability (operationalised as the log of the ratio of annual toothpaste cost to individual annual income) was positively associated with untreated caries prevalence (coefficient = 0.08; 95% CI 0.01–0.16; p = 0.03). GDP per capita (coefficient = −0.003; 95% CI −0.10–0.09; p = 0.94), Gini index (coefficient = −0.002; 95% CI −0.01–0.00; p = 0.47), and sugar availability (coefficient = 0.06; 95% CI −0.03–0.15; p = 0.20) were not statistically significant. Variance inflation factors ranged from 1.14 to 2.54, indicating no material multicollinearity. Discussion To our knowledge, this is the first cross‑national study that quantifies the economic burden of fluoride toothpaste in LMICs and examines its association with the national prevalence of untreated dental caries. Affordability—operationalised as the proportion of median annual income required to purchase a 1‑year supply and modelled on a log scale—was the only covariate significantly associated with caries prevalence after adjustment, whereas GDP per capita, income inequality, and per‑capita refined sugar availability were not. Although the model explained a modest share of variance, the affordability signal was consistent, indicating that consumer prices relative to income may operate as a proximate determinant of population‑level disease burden. Affordability of fluoride toothpaste as a barrier to caries prevention In many LMICs, the out‑of‑pocket cost of fluoride toothpaste represents a non‑trivial share of household resources. Countries such as Tanzania, Solomon Islands, and Senegal exhibited the highest proportional expenditures (with annual costs approaching USD 80), revealing pronounced inequities when benchmarked against national median income. These findings are consistent with prior cross‑country analyses that documented wide disparities in affordability and calling for international action to improve accessibility [10, 11]. While fluoride toothpaste is readily affordable in most high‑income settings—typically accounting for a very small fraction of median income—large segments of the population in LMICs face a materially higher financial burden [10]. Affordability is more than a price tag; it reflects the interplay between consumer prices, income distribution, and purchasing power. Even where nominal prices appear moderate, very low-incomes can render a standard annual supply effectively unaffordable. In several low‑income contexts, households may need to allocate the equivalent of multiple weeks of wages to obtain a year’s supply, placing routine preventive care beyond reach. Within‑country variation further compounds the problem: prices of identical brands can vary substantially by outlet, region, and time, creating volatility that disproportionately affects lower‑income consumers. The public‑health importance of affordability is underscored by the established effectiveness of daily use of fluoride toothpaste. Regular brushing with an adequate concentration is associated with a meaningful reduction in caries incidence in permanent teeth—on the order of one‑quarter—thus, sustained barriers to access have population‑level consequences [8]. The present results suggest that easing the affordability constraint may yield tangible gains in caries prevention, particularly where broader health‑system resources are scarce. Policy levers that reduce the effective price at the point of purchase (e.g. tax exemptions, subsidies, pooled procurement, or incentives for local production) directly target this proximal determinant of preventive behaviour and can be implemented alongside education and service‑integration efforts. Finally, cross‑national price dispersion—including for the same manufacturer’s products— indicates opportunities for market‑shaping strategies and transparency initiatives. Addressing inefficiencies in supply chains and mitigating tariff and tax burdens may help narrow unjustified price differentials across countries, thereby improving equitable access without compromising product quality. Economic disparities and caries prevalence The absence of associations with GDP per capita and the Gini index suggests that macroeconomic context alone does not capture the price‑sensitivity of preventive oral health behaviours. While the Gini index is widely used and interpretable in public‑health research, it is likely too distal to reflect household‑level purchasing constraints relevant to toothpaste acquisition [22]. Accordingly, policy interventions that lower effective consumer prices may deliver measurable benefits even without substantial changes in aggregate economic indicators. Role of Sugar Consumption Despite the well-established association between high sugar intake and dental caries, this study did not detect a significant relationship between the national per capita sugar consumption and caries prevalence. Several factors may explain this finding. First, the use of national-level aggregate data may obscure regional and individual variations in dietary behaviour, oral hygiene practices, and socioeconomic variables. Previous studies indicate that the impact of sugar is moderated by factors such as fluoride exposure, education, and income [23]. Second, the sugar consumption data used in this study were from 2019, which may not reflect recent trends, particularly considering the significant dietary shifts during the COVID-19 pandemic, such as the improved dietary balance and reduced sugar intake in Iranians and increased consumption of high-sugar snacks reported in a review from the United Kingdom [24, 25]. Third, regular use of fluoride toothpaste may reduce the cariogenic effect of high sugar intake. Evidence suggests that populations with consistent fluoride exposure exhibit a reduced incidence of caries despite frequent sugar intake [26], which could explain the null association observed in this study. Taken together, these findings imply that, while reducing sugar consumption remains an important public-health goal, its impact on the incidence of dental caries may be contingent on concurrent access to fluoride-based preventive care. Policy implications and global strategy The findings are consistent with WHO recommendations to address oral health inequities through comprehensive, multisectoral action [27]. Policy levers that directly reduce the effective price paid by consumers—such as removal of import tariffs and value-added taxes on fluoride toothpaste, targeted subsidies or vouchers for low-income households, incentives for local quality-assured production, and pooled or cross-border procurement—are likely to be particularly impactful in LMICs [27]. Embedding oral health promotion within primary health care and community-based programmes can further enhance uptake and adherence. The WHO Global Strategy and Action Plan on Oral Health 2023–2030 (finalised in 2024) explicitly highlights universal access to affordable fluoride toothpaste as part of universal health coverage and recommends fiscal and market-shaping measures to lower prices and stabilise supply. Lessons from global health procurement initiatives such as COVAX—pooled purchasing, advance market commitments, and transparent allocation—offer useful analogues for ensuring equitable access to essential oral health commodities, while recognising differences in scale and urgency between vaccination and oral health prevention [28, 29]. Given the robust effectiveness and favourable cost–effectiveness of fluoride toothpaste, interventions that improve affordability and supply reliability represent feasible, scalable options to reduce the caries burden, particularly in resource‑constrained settings. Limitations and future directions This study’s strengths include its multicountry scope, consistent data processing (standardisation of volume/concentration and price conversion), and a transparent affordability metric anchored to median income. However, some limitations warrant careful interpretation. First, key‑informant sampling of products and prices was non-probabilistic and may have introduced selection and measurement bias. Second, pricing is inherently a market behaviour: there are numerous brands within and across countries, and prices vary by brand, pack size, and formulation, as well as by outlet type (e.g. pharmacy, supermarket, informal vendor), region, and time of production (e.g. manufacturing date or batch). Even for the same brand, consumer prices differ across countries owing to taxes and tariffs, importer margins, transport costs, local competition, promotional discounts, and exchange-rate dynamics. The study relied on point estimates for commonly used products and did not weight prices by market share or capture temporal volatility; consequently, the reported figures represent approximations rather than full market distributions. Third, analyses were ecological at the national level and could not capture subnational heterogeneity or individual‑level behaviours. Fourth, fluoride concentrations were abstracted from labels/packaging without laboratory verification; cross‑country differences in labelling standards may have introduced misclassification. Fifth, the affordability denominator used national median income and did not reflect within-country income distributions; affordability among the lowest‑income deciles was likely underestimated where inequality is pronounced. Sixth, sugar availability and untreated caries prevalence were referenced to 2019 and may not reflected post‑pandemic shifts. Finally, the cross-sectional design precluded causal inference. Future work should implement probability‑based outlet sampling, repeated price audits or automated price-scraping, market-share weighting, and hedonic or PPP-adjusted price indices. Furthermore, future studies should triangulate formal and informal retail channels; verify fluoride content analytically; and explore distribution‑sensitive affordability metrics (e.g. by income decile) within longitudinal or quasi‑experimental evaluations of fiscal and procurement policies. Conclusions Affordability of the fluoride-containing toothpaste (≥950 ppm F) varies markedly across LMICs and, in adjusted analyses, is the only factor associated with national prevalence of untreated dental caries. By contrast, GDP per capita, income inequality and per capita refined sugar availability are not significant predictors at the country level. Substantial cross-national price dispersion—including for identical brands—underscores the need for fiscal and market-shaping measures to lower consumer prices and stabilise supply. Interventions that reduce the effective price at point of purchase (e.g. removal of tariffs and value-added taxes, targeted subsidies or vouchers for low-income households, incentives for local quality-assured production, and pooled or cross-border procurement), alongside integration of oral health promotion within primary health care, are feasible and scalable options in resource-constrained settings. Improving affordability therefore represents an actionable pathway to reduce the burden of untreated dental caries and advance oral health equity. Abbreviations COVID-19 coronavirus disease GDP gross domestic product HICs high-income countries JPY Japanese yen LMICs low- and middle-income countries ppm F parts per million of fluoride USD United States dollar WHO World Health Organization Declarations Ethics approval and consent to participate This study was approved by the International University of Health and Welfare Ethics Committee (Approval No. 22-Im-043). All procedures were conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Written informed consent to participate was obtained from all respondents prior to data collection. Consent for publication Written informed consent for publication was obtained from all participants whose data are presented in a potentially identifiable form. Clinical trial number Clinical trial number: not applicable. Availability of data and materials Data on gross domestic product, Gini index, sugar consumption, and prevalence of untreated dental caries are publicly available from the World Bank and World Health Organization databases. Country-specific toothpaste price data collected through medical professionals in LMICs are not publicly available to protect the confidentiality of contributors, but are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by a Grant-in-Aid for Early-Career Scientists (KAKENHI 22K17442) and by the Alliance for a Cavity-Free Future (ACFF) Research Project 4 (2023). The funders had no role in the decision to submit the manuscript for publication. Authors’ contributions KS and YM conceptualised and designed the study. The survey was administered by KS. ES and DY supervised the statistical analysis and contributed to interpretation of the findings. All authors reviewed and edited the manuscript and participated in the overall supervision of the study. All authors are accountable for the accuracy and integrity of the work, and have read and approved the final version of the manuscript. The corresponding author had full access to all data and assumes the final responsibility for the decision to submit the manuscript for publication. Acknowledgments The authors thank all participants. We thank Dr. Syozi Nakashima for his valuable assistance with the chemical aspect of toothpaste. We also express our sincere appreciation to the JICA Health Management Center for their cooperation in supporting survey implementation. We thank Editage (www.editage.jp) for English language editing. Generative AI and AI-assisted technologies in the writing process ChatGPT was used to enhance the language used in this manuscript. However, all content in the manuscript was created solely by the authors. References Wen PY, Chen MX, Zhong YJ, Dong QQ, Wong HM. Global burden and inequality of dental caries, 1990 to 2019. J Dent Res. 2022;101:392–9. Alsuraim BS, Han DH. Effect of globalization on global dental caries trend. Med (Baltim). 2020;99:e21767. https://doi.org/10.1097/MD.0000000000021767 . Goldfeld SA, Francis KL, O’Connor E, Ludvigsson J, Faresjö T, Nikiema B, et al. 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Tables Table 1 Fluoride toothpaste price and economic indicators for 45 countries across five regions Region Country Cost of purchasing fluoride toothpaste (USD/year) in 2023 Ratio of fluoride purchase cost to annual income (%) Fluoride concentration of the toothpastes (ppm F) Per capita availability of refined sugar (g/day) in 2019 Prevalence of untreated permanent tooth caries (ages 5+) in 2019 GDP per capita, PPP (current international $) (2023) Gini index Asia (15) Bangladesh 29.9 0.33 1216.67 16.9 30.4 9147.78 30.9 Bhutan 16.24 0.14 958.5 - 29.7 16253.96 28.5 Cambodia 35.25 0.74 1202.33 73.2 31.4 7430.73 - Indonesia 11.66 0.12 1295.33 66.1 28.8 15415.71 36.1 Kyrgyz Republic 20.26 0.3 1300 37.5 35.0 7298.09 27.2 Lao PDR 26.36 0.37 1475 23.4 22.8 9291.79 38.8 Malaysia 50.6 0.16 1098 116.1 22.8 36416.54 40.7 Myanmar 4.91 0.10 1450 8.5 31.5 5953.36 30.7 Nepal 12.9 0.21 924.00 18.8 35.9 5395.21 30 Papua New Guinea 38.57 0.91 1283.33 26.8 29.4 4667.84 41.9 Philippines 22.85 0.23 1000 57.8 27.4 10985.83 39.3 Sri Lanka 8.7 0.09 1250 75.5 35.0 14455.65 37.7 Tajikistan 15.99 0.24 1450 49.1 27.0 4963.58 33.5 Thailand 32.56 0.28 1476.67 117.3 28.0 23519.21 33.5 Vietnam 52.49 0.46 1182.67 27.6 28.4 15033.88 36.1 Africa (15) Botswana 11.97 0.1 1450 62.3 32.7 7178.34 54.9 Congo, Dem. Rep 12.87 0.86 1368 - - 1616.47 44.7 Djibouti 46.0 0.74 1450 112.8 31.1 7264.04 41.6 Ethiopia 16.87 0.39 1450 26.0 27.5 3060.91 31.1 Gabon 27.15 0.16 1450 47.0 28.1 20757.07 38 Ghana 12.18 0.18 1450 30.7 25.3 7556.42 43.5 Kenya 21.59 0.38 1283.33 47.3 24.0 6307.23 37.7 Malawi 25.96 1.28 1450 15.4 31.4 1829.51 38.5 Morocco 31.78 0.38 1450 91.8 36.0 9842.89 39.5 Mozambique 21.07 1.42 1450 34.0 33.4 1677.68 49.6 Senegal 77.17 1.61 1374.59 44.5 38.5 4777.61 36.2 South Africa 22.84 0.28 1379 82.1 28.4 15194.2 63 Tanzania 87.26 2.33 1360.3 - - 4,018.52 40.5 Tunisia 19.97 0.21 1450 90.6 34.8 14009.52 33.7 Uganda 10.52 0.32 1450 31.0 24.9 3,097.64 42.7 Oceania (5) Fiji 48.20 0.33 1225 61.9 35.2 15,152.14 30.7 Maldives 31.31 0.18 1359.2 62.8 28.0 24,735.08 29.3 Palau 30.50 0.21 1044 61.1 34.9 17531.69 Samoa 24.93 0.18 1300 29.0 36.2 7037.09 38.7 Solomon Islands 62.86 1.83 1300 - 36.9 2800.82 37.1 Middle East (2) Egypt, Arab Rep. 17.88 0.10 1441.67 70.9 30.4 18524.84 28.5 Jordan 25.09 0.3 1300 82.0 38.5 10411.84 33.7 Latin America (8) Brazil 39.69 0.35 1325.33 107.8 25.9 21175.62 51.6 Costa Rica 76.24 0.42 1432.00 130.4 40.7 28075.14 46.7 Ecuador 44.17 0.35 1442 55.7 38.7 15918.52 44.6 El Salvador 52.46 0.42 1442 113.1 30.6 12679.58 39.8 Honduras 24.5 0.42 1450 111.8 31.1 7178.34 46.8 Jamaica 33.07 0.41 1160.4 134.8 30.1 11466.97 34.3 Nicaragua 26.42 0.4 1450 112.2 31.1 8319.98 46.2 Panama 27.32 0.09 1332.67 63.2 32.7 39803.32 48.9 USD, United States dollar; GDP, gross domestic product; PPP, purchasing power parity Table 2 Linear regression for factors associated with prevalence of caries Coefficients (95% CI) p- values Intercept 3.41 (2.73–4.09) < 0.01 GDP per capita (log) −0.003 (− 0.10–0.09) 0.94 Gini index −0.002 (− 0.01–0.00) 0.47 Sugar consumption (log) 0.06 (-0.03–0.15) 0.2 Affordability of fluoride toothpaste (log) 0.08 (0.01–0.16) 0.03 GDP, gross domestic product; CI, confidence interval Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1SurveyQuestionnaireEnglish.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 May, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviews received at journal 07 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers invited by journal 07 Jan, 2026 Editor invited by journal 02 Jan, 2026 Editor assigned by journal 17 Oct, 2025 Submission checks completed at journal 16 Oct, 2025 First submitted to journal 16 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":660797,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of the annual income required to purchase fluoride toothpaste for twice daily use\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7707685/v1/85003418598b276de5062845.jpeg"},{"id":100377175,"identity":"93d7fc75-56f2-4466-bf5e-b7b3ee1b19a5","added_by":"auto","created_at":"2026-01-16 08:47:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1716058,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7707685/v1/99481ac0-ea55-448b-af9b-dda0cc669ccb.pdf"},{"id":100358864,"identity":"3f1c8fd8-cba2-4063-98ba-42a24d6e8984","added_by":"auto","created_at":"2026-01-16 07:21:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29546,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1SurveyQuestionnaireEnglish.docx","url":"https://assets-eu.researchsquare.com/files/rs-7707685/v1/01024d73da909aecbccb1231.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Affordability of fluoride toothpaste and national prevalence of untreated dental caries in low- and middle-income countries: an ecological cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eOral diseases are among the most widespread non-communicable health challenges globally; they significantly affect the quality of life and impose considerable burdens on healthcare systems.\u003c/p\u003e \u003cp\u003eAlthough a global downward trend in dental caries prevalence has been reported, particularly in high-income countries (HICs), substantial disparities persist between HICs and low- and middle-income countries (LMICs). Over the past three decades, HICs have reported an approximately 40% reduction in caries prevalence, with age-standardised rates declining by 3.6% and 3.0% between 1990 and 2019 in the permanent and primary dentitions, respectively [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, LMICs continue to face significant challenges owing to systemic inequities in access to care, quality of services, treatment costs, oral health education, and overall health literacy [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The determinants of oral diseases in LMICs are multifactorial, involving individual, sociocultural, environmental, and economic factors.\u003c/p\u003e \u003cp\u003eAddressing oral health disparities requires comprehensive, context-specific preventive strategies. These include the widespread use of fluoride, improved oral health education, school- and community-based preventive initiatives, integration of oral healthcare into primary health systems, and development of supportive public health policies [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Among these, the use of fluoride and oral health education are particularly cost-effective and scalable interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Brushing with a fluoride toothpaste combines mechanical plaque removal with the chemical prevention of dental caries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The World Health Organization (WHO) recommends fluoride concentrations of 1000\u0026ndash;1500 parts per million of fluoride (ppm F) for all age groups, and recognising its essential role in dental-caries prevention, added fluoride toothpaste to its Model List of Essential Medicines in 2021 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite international guidelines, affordability of fluoride toothpaste remains inconsistent across income levels. In many low-income settings, out-of-pocket expenditures for oral healthcare pose a significant burden on household finances, making fluoride toothpaste inaccessible for a substantial portion of the population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This limited accessibility may contribute to the persistently high prevalence of dental caries in these regions.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to assess the affordability of \u0026ge;\u0026thinsp;950 ppm F toothpaste, which are the most common commercially available concentrations, for individuals residing in LMICs. Specifically, we calculated the proportion of household income required to purchase fluoride toothpaste and examined the association between affordability and the national dental caries prevalence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eA cross-sectional survey was conducted between January and March 2023 in LMICs to examine the affordability of toothpaste containing fluoride at concentrations effective for preventing dental caries. Data collection was facilitated by international organisations in Japan, enabling responses from 60 countries.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eSurvey participants were selected from medical professionals who had extensive work experience in developing countries and were affiliated with Japanese government agencies. These individuals were chosen because of their familiarity with local pharmaceutical products and living conditions, which allowed them to understand the research objectives and carry out the survey effectively, even in resource-constrained settings. Recruitment was conducted through existing networks of international organisations. A representative from a Japanese government organisation contacted medical professionals working abroad via email and invited them to participate in the survey. Those who expressed interest were provided with a detailed explanation of the study\u0026rsquo;s purpose, procedures, and confidentiality measures. Written informed consent was obtained from all participants following a full explanation of the study purpose, methods and secondary use of the data. The questionnaire was then sent directly by the principal investigator. As a token of appreciation, participants received shopping points equivalent to 4,000 JPY.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eParticipants were instructed to consult local colleagues affiliated with international organisations and to select at least two\u0026mdash;and preferably three\u0026mdash;commonly available toothpaste products for purchase in their country. For each product, the survey captured the fluoride status (present/absent as stated on the primary packaging), product name, manufacturer or distributor, fluoride concentration (grams or ppm F), and net content (millilitres or grams). When fluoride status or concentration was uncertain, participants were asked to photograph the packaging and transcribe the stated fluoride information. To ensure consistency across regions, data were collected using a self-administered questionnaire. An English version of the questionnaire, developed specifically for this study, is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eAll toothpaste products were standardised in terms of volume, while fluoride concentration and price per product were calculated based on the standardised volume. Products without information regarding the fluoride concentration were excluded. However, products containing 950 ppm F were included because their clinical efficacy is chemically comparable to that of products containing 1,000 ppm F [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Participants were requested to submit photographs of the primary containers and outer packaging, if available, for reference.\u003c/p\u003e \u003cp\u003eStandardisation of toothpaste volume\u003c/p\u003e \u003cp\u003eOwing to differences in the net volume in millilitres or net mass in grams across products and because the fluoride concentration was expressed in micrograms per gram or percentage of mass, standardisation was necessary. The toothpaste volume in millilitres was converted to grams at an assumed density of 1.3 grams/ millilitres [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The fluoride concentration as a percentage of mass was converted to ppm F using the molecular weight of sodium fluoride, acidulated phosphate fluoride, or sodium monofluorophosphate.\u003c/p\u003e \u003cp\u003ePrice conversion\u003c/p\u003e \u003cp\u003eOnly fluoride-containing toothpastes (\u0026ge;\u0026thinsp;950 ppm F) were included in the analysis. Prices were converted to United States dollars (USD) using the average exchange rates for the first half of 2023, as reported by the World Bank [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eToothpaste usage and its cost\u003c/p\u003e \u003cp\u003eBased on previous studies, the amount of fluoride toothpaste consumed by an adult per instance was assumed to be 1.5 g [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The annual toothpaste consumption was calculated based on a twice daily brushing frequency.\u003c/p\u003e \u003cp\u003eAffordability of fluoride toothpaste\u003c/p\u003e \u003cp\u003eThe affordability of fluoride toothpaste in each LMIC was defined as the ratio of the yearly cost of the toothpaste to the annual income of individuals according to the 2023 median income data obtained from Our World in Data [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSelection of variables\u003c/p\u003e \u003cp\u003eThe associations between caries prevalence and fluoride toothpaste prices in 2023, median annual income in 2023, economic indicators (gross domestic product [GDP] and Gini index) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and annual sugar consumption were analysed. Sugar consumption was selected as a key factor associated with caries risk based on the WHO dietary recommendations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The latest Gini index values were obtained from the World Bank database [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Gini coefficients range from 0 to 1, and values\u0026thinsp;\u0026gt;\u0026thinsp;0.5 indicate substantial income inequality.\u003c/p\u003e \u003cp\u003eUse of secondary data\u003c/p\u003e \u003cp\u003eSugar consumption data were initially sourced from WHO. However, owing to the suspension of data collection in 2022 during the coronavirus disease (COVID-19) pandemic, data from 2019 were used instead [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similarly, the national prevalence of untreated dental caries was obtained from the 2019 comprehensive WHO dataset, which reports estimates for individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;5 years [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eMultiple linear regression analysis was performed, with dental caries prevalence as the dependent variable. The independent variables included the proportion of annual income required to purchase fluoride toothpaste, GDP, Gini index, and per capita sugar consumption. All variables, except the Gini index, were log-transformed to meet the assumption of normality. Multicollinearity among independent variables was evaluated using variance inflation factors. Statistical analyses were performed using SPSS Statistics (version 29.0; IBM Corp., Armonk, NY).\u003c/p\u003e \u003c/div\u003e\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the International University of Health and Welfare Ethics Committee (Approval No. 22-Im-043). All procedures were conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Written informed consent to participate was obtained from all respondents prior to data collection.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCountry participation and products\u003c/p\u003e\n\u003cp\u003eOf 54 countries with participants who provided initial consent, survey responses were obtained from 45 countries. An average of 5 toothpastes per country was reported (241 entries in total), of which 170 had verified fluoride concentrations.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics\u003c/p\u003e\n\u003cp\u003eTable 1 presents fluoride toothpaste prices and economic indicators for 45 countries across five regions. Across the 45 LMICs, the mean annual cost of fluoride toothpaste was USD 30.87 (standard deviation [SD] 18.74; range, 4.91\u0026ndash;87.26). The mean fluoride concentration of the toothpastes was 1,329.6 ppm F (SD 147.19; range, 924\u0026ndash;1,476.67). The affordability ratio averaged 0.48% (SD 0.49%; range, 0.09\u0026ndash;2.33). Mean per capita refined sugar availability was 64.06 grams/day (SD 35.55; range, 8.5\u0026ndash;134.8), mean prevalence of untreated caries 31.18% (SD 4.47%; range 22.8\u0026ndash;40.7), mean GDP per capita USD 11,893.96 (SD 8,697.08), and mean Gini index 39 (SD 7.66).\u003c/p\u003e\n\u003cp\u003eAssociation with caries prevalence\u003c/p\u003e\n\u003cp\u003eTable 2 summarises the regression results. Affordability (operationalised as the log of the ratio of annual toothpaste cost to individual annual income) was positively associated with untreated caries prevalence (coefficient = 0.08; 95% CI 0.01\u0026ndash;0.16; p = 0.03). GDP per capita (coefficient = \u0026minus;0.003; 95% CI \u0026minus;0.10\u0026ndash;0.09; p = 0.94), Gini index (coefficient = \u0026minus;0.002; 95% CI \u0026minus;0.01\u0026ndash;0.00; p = 0.47), and sugar availability (coefficient = 0.06; 95% CI \u0026minus;0.03\u0026ndash;0.15; p = 0.20) were not statistically significant. Variance inflation factors ranged from 1.14 to 2.54, indicating no material multicollinearity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first cross‑national study that quantifies the economic burden of fluoride toothpaste in LMICs and examines its association with the national prevalence of untreated dental caries. Affordability—operationalised as the proportion of median annual income required to purchase a 1‑year supply and modelled on a log scale—was the only covariate significantly associated with caries prevalence after adjustment, whereas GDP per capita, income inequality, and per‑capita refined sugar availability were not. Although the model explained a modest share of variance, the affordability signal was consistent, indicating that consumer prices relative to income may operate as a proximate determinant of population‑level disease burden.\u003c/p\u003e\n\u003cp\u003eAffordability of fluoride toothpaste as a barrier to caries prevention\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn many LMICs, the out‑of‑pocket cost of fluoride toothpaste represents a non‑trivial share of household resources. Countries such as Tanzania, Solomon Islands, and Senegal exhibited the highest proportional expenditures (with annual costs approaching USD 80), revealing pronounced inequities when benchmarked against national median income. These findings are consistent with prior cross‑country analyses that documented wide disparities in affordability and calling for international action to improve accessibility [10, 11]. While fluoride toothpaste is readily affordable in most high‑income settings—typically accounting for a very small fraction of median income—large segments of the population in LMICs face a materially higher financial burden [10].\u003c/p\u003e\n\u003cp\u003eAffordability is more than a price tag; it reflects the interplay between consumer prices, income distribution, and purchasing power. Even where nominal prices appear moderate, very low-incomes can render a standard annual supply effectively unaffordable. In several low‑income contexts, households may need to allocate the equivalent of multiple weeks of wages to obtain a year’s supply, placing routine preventive care beyond reach. Within‑country variation further compounds the problem: prices of identical brands can vary substantially by outlet, region, and time, creating volatility that disproportionately affects lower‑income consumers.\u003c/p\u003e\n\u003cp\u003eThe public‑health importance of affordability is underscored by the established effectiveness of daily use of fluoride toothpaste. Regular brushing with an adequate concentration is associated with a meaningful reduction in caries incidence in permanent teeth—on the order of one‑quarter—thus, sustained barriers to access have population‑level consequences [8]. The present results suggest that easing the affordability constraint may yield tangible gains in caries prevention, particularly where broader health‑system resources are scarce. Policy levers that reduce the effective price at the point of purchase (e.g. tax exemptions, subsidies, pooled procurement, or incentives for local production) directly target this proximal determinant of preventive behaviour and can be implemented alongside education and service‑integration efforts.\u003c/p\u003e\n\u003cp\u003eFinally, cross‑national price dispersion—including for the same manufacturer’s products—\u0026nbsp;indicates opportunities for market‑shaping strategies and transparency initiatives. Addressing inefficiencies in supply chains and mitigating tariff and tax burdens may help narrow unjustified price differentials across countries, thereby improving equitable access without compromising product quality.\u003c/p\u003e\n\u003cp\u003eEconomic disparities and caries prevalence\u003c/p\u003e\n\u003cp\u003eThe absence of associations with GDP per capita and the Gini index suggests that macroeconomic context alone does not capture the price‑sensitivity of preventive oral health behaviours. While the Gini index is widely used and interpretable in public‑health research, it is likely too distal to reflect household‑level purchasing constraints relevant to toothpaste acquisition [22]. Accordingly, policy interventions that lower effective consumer prices may deliver measurable benefits even without substantial changes in aggregate economic indicators.\u003c/p\u003e\n\u003cp\u003eRole of Sugar Consumption\u003c/p\u003e\n\u003cp\u003eDespite the well-established association between high sugar intake and dental caries, this study did not detect a significant relationship between the national per capita sugar consumption and caries prevalence. Several factors may explain this finding. First, the use of national-level aggregate data may obscure regional and individual variations in dietary behaviour, oral hygiene practices, and socioeconomic variables. Previous studies indicate that the impact of sugar is moderated by factors such as fluoride exposure, education, and income [23]. Second, the sugar consumption data used in this study were from 2019, which may not reflect recent trends, particularly considering the significant dietary shifts during the COVID-19 pandemic, such as the improved dietary balance and reduced sugar intake in Iranians and increased consumption of high-sugar snacks reported in a review from the United Kingdom [24, 25]. Third, regular use of fluoride toothpaste may reduce the cariogenic effect of high sugar intake. Evidence suggests that populations with consistent fluoride exposure exhibit a reduced incidence of caries despite frequent sugar intake [26], which could explain the null association observed in this study. Taken together, these findings imply that, while reducing sugar consumption remains an important public-health goal, its impact on the incidence of dental caries may be contingent on concurrent access to fluoride-based preventive care.\u003c/p\u003e\n\u003cp\u003ePolicy implications and global strategy\u003c/p\u003e\n\u003cp\u003eThe findings are consistent with WHO recommendations to address oral health inequities through comprehensive, multisectoral action [27]. Policy levers that directly reduce the effective price paid by consumers—such as removal of import tariffs and value-added taxes on fluoride toothpaste, targeted subsidies or vouchers for low-income households, incentives for local quality-assured production, and pooled or cross-border procurement—are likely to be particularly impactful in LMICs [27]. Embedding oral health promotion within primary health care and community-based programmes can further enhance uptake and adherence.\u003c/p\u003e\n\u003cp\u003eThe WHO Global Strategy and Action Plan on Oral Health 2023–2030 (finalised in 2024) explicitly highlights universal access to affordable fluoride toothpaste as part of universal health coverage and recommends fiscal and market-shaping measures to lower prices and stabilise supply. Lessons from global health procurement initiatives such as COVAX—pooled purchasing, advance market commitments, and transparent allocation—offer useful analogues for ensuring equitable access to essential oral health commodities, while recognising differences in scale and urgency between vaccination and oral health prevention [28, 29].\u003c/p\u003e\n\u003cp\u003eGiven the robust effectiveness and favourable cost–effectiveness of fluoride toothpaste, interventions that improve affordability and supply reliability represent feasible, scalable options to reduce the caries burden, particularly in resource‑constrained settings.\u003c/p\u003e\n\u003cp\u003eLimitations and future directions\u003c/p\u003e\n\u003cp\u003eThis study’s strengths include its multicountry scope, consistent data processing (standardisation of volume/concentration and price conversion), and a transparent affordability metric anchored to median income. However, some limitations warrant careful interpretation. First, key‑informant sampling of products and prices was non-probabilistic and may have introduced selection and measurement bias. Second, pricing is inherently a market behaviour: there are numerous brands within and across countries, and prices vary by brand, pack size, and formulation, as well as by outlet type (e.g. pharmacy, supermarket, informal vendor), region, and time of production (e.g. manufacturing date or batch). Even for the same brand, consumer prices differ across countries owing to taxes and tariffs, importer margins, transport costs, local competition, promotional discounts, and exchange-rate dynamics. The study relied on point estimates for commonly used products and did not weight prices by market share or capture temporal volatility; consequently, the reported figures represent approximations rather than full market distributions. Third, analyses were ecological at the national level and could not capture subnational heterogeneity or individual‑level behaviours. Fourth, fluoride concentrations were abstracted from labels/packaging without laboratory verification; cross‑country differences in labelling standards may have introduced misclassification. Fifth, the affordability denominator used national median income and did not reflect within-country income distributions; affordability among the lowest‑income deciles was likely underestimated where inequality is pronounced. Sixth, sugar availability and untreated caries prevalence were referenced to 2019 and may not reflected post‑pandemic shifts. Finally, the cross-sectional design precluded causal inference. Future work should implement probability‑based outlet sampling, repeated price audits or automated price-scraping, market-share weighting, and hedonic or PPP-adjusted price indices. Furthermore, future studies should triangulate formal and informal retail channels; verify fluoride content analytically; and explore distribution‑sensitive affordability metrics (e.g. by income decile) within longitudinal or quasi‑experimental evaluations of fiscal and procurement policies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAffordability of the fluoride-containing toothpaste (≥950 ppm F) varies markedly across LMICs and, in adjusted analyses, is the only factor associated with national prevalence of untreated dental caries. By contrast, GDP per capita, income inequality and per capita refined sugar availability are not significant predictors at the country level. Substantial cross-national price dispersion—including for identical brands—underscores the need for fiscal and market-shaping measures to lower consumer prices and stabilise supply. Interventions that reduce the effective price at point of purchase (e.g. removal of tariffs and value-added taxes, targeted subsidies or vouchers for low-income households, incentives for local quality-assured production, and pooled or cross-border procurement), alongside integration of oral health promotion within primary health care, are feasible and scalable options in resource-constrained settings. Improving affordability therefore represents an actionable pathway to reduce the burden of untreated dental caries and advance oral health equity.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOVID-19\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecoronavirus disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egross domestic product\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehigh-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJPY\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJapanese yen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eppm F\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eparts per million of fluoride\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States dollar\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the International University of Health and Welfare Ethics Committee (Approval No. 22-Im-043). All procedures were conducted in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Written informed consent to participate was obtained from all respondents prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants whose data are presented in a potentially identifiable form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e\u003cstrong\u003e of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on gross domestic product, Gini index, sugar consumption, and prevalence of untreated dental caries are publicly available from the World Bank and World Health Organization databases. Country-specific toothpaste price data collected through medical professionals in LMICs are not publicly available to protect the confidentiality of contributors, but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a Grant-in-Aid for Early-Career Scientists (KAKENHI 22K17442) and by the Alliance for a Cavity-Free Future (ACFF) Research Project 4 (2023). The funders had no role in the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKS and YM conceptualised and designed the study. The survey was administered by KS. ES and DY supervised the statistical analysis and contributed to interpretation of the findings. All authors reviewed and edited the manuscript and participated in the overall supervision of the study. All authors are accountable for the accuracy and integrity of the work, and have read and approved the final version of the manuscript. The corresponding author had full access to all data and assumes the final responsibility for the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participants.\u003c/p\u003e\n\u003cp\u003eWe thank Dr. Syozi Nakashima for his valuable assistance with the chemical aspect of toothpaste. We also express our sincere appreciation to the JICA Health Management Center for their cooperation in supporting survey implementation.\u003c/p\u003e\n\u003cp\u003eWe thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGenerative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChatGPT was used to enhance the language used in this manuscript. However, all content in the manuscript was created solely by the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWen PY, Chen MX, Zhong YJ, Dong QQ, Wong HM. Global burden and inequality of dental caries, 1990 to 2019. J Dent Res. 2022;101:392\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsuraim BS, Han DH. Effect of globalization on global dental caries trend. 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Accessed 19 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Per capita availability of refined sugar (g/day). 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/indicators/indicator-details/GHO/ORALHEALTH_SUGAR_AVAILABILITY\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/indicators/indicator-details/GHO/ORALHEALTH_SUGAR_AVAILABILITY\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Prevalence of untreated caries of permanent teeth in people aged\u0026thinsp;\u0026ge;\u0026thinsp;5 years (%). 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-untreated-caries-of-permanent-teeth-in-people-5-years\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-untreated-caries-of-permanent-teeth-in-people-5-years\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharles V, Gherman T, Paliza JC. The Gini index: a modern measure of inequality. In: Charles V, Emrouznejad A, editors. Modern indices for international economic diplomacy. Cham: Springer; 2022. pp. 55\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheever VJ, Mohajeri A, Patel K, Burris RC, Hung M. Impact of free sugar consumption on dental caries: a cross-sectional analysis of children in the United States. Dent J (Basel). 2025;13:48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/dj13020048\u003c/span\u003e\u003cspan address=\"10.3390/dj13020048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDicken SJ, Mitchell JJ, Le Newberry J, Beard E, Kale D, Herbec A, et al. Impact of the COVID-19 pandemic on diet behaviour among UK adults: a longitudinal analysis of the HEBECO study. Front Nutr. 2021;8:788043. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fnut.2021.788043\u003c/span\u003e\u003cspan address=\"10.3389/fnut.2021.788043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRafraf M, Molani-Gol R, Sahebjam M. Effect of COVID-19 pandemic on eating habits and lifestyle of college students in Tabriz, Iran: a cross-sectional study. Front Public Health. 2023;11:1185681. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2023.1185681\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2023.1185681\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelough MM, Sathyanarayana S, Zohoori FV, Gustafsson HC, Sullivan EL, Chi DL, et al. Impact of fluoride on associations between free sugars intake and dental caries in US children. JDR Clin Trans Res. 2023;8:215\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global strategy and action plan on oral health 2023\u0026ndash;30. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/376623/9789240090538-eng.pdf\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/376623/9789240090538-eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 25 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. COVID-19 vaccinations shift to regular immunization as COVAX draws to a close. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/19-12-2023-covid-19-vaccinations-shift-to-regular-immunization-as-covax-draws-to-a-close\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/19-12-2023-covid-19-vaccinations-shift-to-regular-immunization-as-covax-draws-to-a-close\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 25 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCullinan K. COVAX vaccines helped avert 2.7 million COVID deaths \u0026ndash; but could have saved more with stable regional supplies. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://healthpolicy-watch.news/covax-vaccines-helped-avert-2-7-million-covid-deaths-but-could-have-saved-more-with-stable-regional-supplies\u003c/span\u003e\u003cspan address=\"https://healthpolicy-watch.news/covax-vaccines-helped-avert-2-7-million-covid-deaths-but-could-have-saved-more-with-stable-regional-supplies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 25 Jun 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFluoride toothpaste price and economic indicators for 45 countries across five regions\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eRegion\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCountry\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCost of purchasing fluoride toothpaste (USD/year) in 2023\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eRatio of fluoride purchase cost to annual income (%)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFluoride concentration of the toothpastes (ppm F)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePer capita availability of refined sugar (g/day) in 2019\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePrevalence of untreated permanent tooth caries\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(ages 5+) in 2019\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGDP per capita, PPP (current international $) (2023)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGini index\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"15\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAsia (15)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBangladesh\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e29.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1216.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9147.78\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.9\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBhutan\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.24\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.14\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e958.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e29.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16253.96\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCambodia\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e35.25\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.74\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1202.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e73.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7430.73\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIndonesia\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11.66\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.12\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1295.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e66.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15415.71\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.1\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eKyrgyz Republic\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e20.26\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1300\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e37.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e35.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7298.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.2\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLao PDR\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e26.36\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.37\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1475\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9291.79\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.8\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMalaysia\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e50.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.16\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1098\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e116.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36416.54\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e40.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMyanmar\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.91\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.10\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5953.36\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNepal\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.21\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e924.00\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e18.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e35.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5395.21\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePapua New Guinea\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.57\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.91\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1283.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e26.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e29.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4667.84\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e41.9\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePhilippines\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.85\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.23\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1000\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e57.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e10985.83\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e39.3\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSri Lanka\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1250\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e75.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e35.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e14455.65\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e37.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTajikistan\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15.99\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.24\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e49.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4963.58\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThailand\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e32.56\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.28\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1476.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e117.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23519.21\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eVietnam\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e52.49\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.46\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1182.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15033.88\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.1\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"15\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAfrica (15)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBotswana\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11.97\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e62.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e32.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7178.34\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e54.9\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCongo, Dem. Rep\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12.87\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.86\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1368\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1616.47\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e44.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDjibouti\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e46.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.74\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e112.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7264.04\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e41.6\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eEthiopia\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.87\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.39\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e26.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3060.91\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.1\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGabon\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.15\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.16\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e47.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e20757.07\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGhana\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12.18\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.18\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7556.42\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e43.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eKenya\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e21.59\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.38\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1283.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e47.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6307.23\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e37.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMalawi\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.96\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.28\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1829.51\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMorocco\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.78\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.38\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e91.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9842.89\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e39.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMozambique\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e21.07\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.42\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e34.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1677.68\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e49.6\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSenegal\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e77.17\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.61\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1374.59\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e44.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4777.61\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.2\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSouth Africa\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.84\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.28\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1379\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e82.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15194.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e63\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTanzania\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e87.26\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1360.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4,018.52\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e40.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTunisia\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e19.97\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.21\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e90.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e34.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e14009.52\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eUganda\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e10.52\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.32\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3,097.64\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e42.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eOceania (5)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFiji\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e48.20\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1225\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e61.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e35.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e15,152.14\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMaldives\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.31\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.18\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1359.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e62.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24,735.08\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e29.3\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePalau\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.50\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.21\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1044\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e61.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e34.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e17531.69\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSamoa\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24.93\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.18\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1300\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e29.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7037.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSolomon Islands\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e62.86\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.83\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1300\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2800.82\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e37.1\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMiddle East (2)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eEgypt, Arab Rep.\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e17.88\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.10\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1441.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e70.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e18524.84\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e28.5\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eJordan\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1300\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e82.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e10411.84\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.7\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"8\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLatin America (8)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBrazil\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e39.69\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.35\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1325.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e107.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv 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class=\"SimplePara\"\u003e46.8\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eJamaica\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.07\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.41\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1160.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e134.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11466.97\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e34.3\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNicaragua\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e26.42\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1450\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e112.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e31.1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8319.98\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e46.2\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePanama\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.32\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1332.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e63.2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e32.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e39803.32\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e48.9\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\"\u003eUSD, United States dollar; GDP, gross domestic product; PPP, purchasing power parity\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLinear regression for factors associated with prevalence of caries\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCoefficients\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(95% CI)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003ep-\u003c/span\u003evalues\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eIntercept\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3.41\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(2.73\u0026ndash;4.09)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.01\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eGDP per capita\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003e(log)\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026minus;0.003\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(\u0026minus;\u0026thinsp;0.10\u0026ndash;0.09)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.94\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eGini index\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026minus;0.002\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(\u0026minus;\u0026thinsp;0.01\u0026ndash;0.00)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.47\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eSugar consumption\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003e(log)\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.06\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(-0.03\u0026ndash;0.15)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.2\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eAffordability of fluoride toothpaste\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003e(log)\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.08\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(0.01\u0026ndash;0.16)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.03\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eGDP, gross domestic product; CI, confidence interval\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"affordability, fluoride toothpaste, low- and middle-income countries, dental caries","lastPublishedDoi":"10.21203/rs.3.rs-7707685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7707685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDental caries disproportionately affects low- and middle-income countries (LMICs), where access to fluoride toothpaste is often limited by poor affordability. This study aimed to assess the affordability of \u0026ge;\u0026thinsp;950 parts per million of fluoride (ppm F) toothpaste for the general population in LMICs and its association with the prevalence of untreated dental caries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross‑sectional ecological survey was conducted between January and March 2023. Key-informants\u0026mdash;medical professionals with extensive experience in LMICs\u0026mdash;reported brand, fluoride concentration, pack size, and price for commonly used toothpastes. Prices were converted to United States dollars using average 2023 exchange-rates, product volumes were standardised to grams, and annual consumption assumed 3 g/day (twice daily brushing). Affordability was defined as the proportion of 2023 median annual income required to purchase a 1‑year supply per person. National prevalence of untreated caries (ages\u0026thinsp;\u0026ge;\u0026thinsp;5 years), per capita refined sugar availability (2019), gross domestic product (GDP) per capita (PPP), and Gini index were assembled from international databases. Multiple linear regression assessed associations between caries prevalence and affordability, adjusting for GDP, Gini, and sugar; log‑transformations were applied except for Gini.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eData were obtained for 45 LMICs across Asia, Africa, Oceania, Latin America, and the Middle East. The mean annual cost of fluoride toothpaste was USD 30.87 (SD 18.74; range 4.91\u0026ndash;87.26). The mean affordability ratio was 0.48% (SD 0.49%; range 0.09\u0026ndash;2.33%). In regression analyses, only affordability showed a significant positive association with untreated caries prevalence (coefficient 0.08; 95% CI 0.01\u0026ndash;0.16; p\u0026thinsp;=\u0026thinsp;0.03); GDP per capita, Gini index, and sugar availability were not significant.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAffordability of \u0026ge;\u0026thinsp;950 ppm F toothpaste varies substantially across LMICs and is significantly associated with the national prevalence of untreated dental caries.\u003c/p\u003e","manuscriptTitle":"Affordability of fluoride toothpaste and national prevalence of untreated dental caries in low- and middle-income countries: an ecological cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 12:51:58","doi":"10.21203/rs.3.rs-7707685/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"78455485233973905243817774584204662647","date":"2026-05-14T17:42:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337490623642576298760661990209442883085","date":"2026-04-22T21:47:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T20:37:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T08:51:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99185486257155338485288131230071234745","date":"2026-03-25T06:10:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291511711517108617363657014554025340878","date":"2026-03-20T00:09:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T11:14:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-02T07:30:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-17T07:10:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-16T07:39:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-16T07:36:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6074f20-a723-4d3d-92ad-2ad653351b62","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"78455485233973905243817774584204662647","date":"2026-05-14T17:42:28+00:00","index":121,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T12:51:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 12:51:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7707685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7707685","identity":"rs-7707685","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}